In a presentation at an annual meeting of the Pacific Coast Obstetrical and Gynecological Society, researchers described similar issues among labor and delivery staff:
“When a nurse reported to the physician that her patient was highly anxious and had shortness of breath, the physician told the nurse to give the patient some Ativan and take some herself. Later that evening the patient was admitted to the ICU with congestive heart failure.”
“A nurse reported that the final sponge count was incorrect after a difficult tubal ligation. The physician was sarcastic and said that an expensive X-ray would be ordered because the nurse obviously suffered from obsessive-compulsive disorder. A sponge was found in the patient.”
“Doctor’s behavior has been hostile, aggressive, threatening, and escalating in the past months . . . including raging at charge nurses and unit director. . . . [L&D] nurses are working in a hostile environment and fear for their safety and well-being.”
It is important to note that these types of behavior are exhibited by some doctors, not all, and that incidents should be viewed in proper context. Tensions run high in life-or-death situations, and doctors may not have time to temper their tone or monitor their language when their priority is saving a life. The doctors considered the worst offenders are the specialists whose work is consistently urgent and carries the highest stakes. Doctors and nurses have reported that the most frequent bullies are general surgeons, cardiovascular surgeons, cardiologists, orthopedic surgeons, neurosurgeons, and neurologists. The hospital departments most likely to host doctor bullying are ORs, medical surgery units, ICUs, and ERs. In the OR, attending surgeons are more than twice as likely as anesthesiologists and nurses to exhibit this kind of behavior.
An American College of Physician Executives survey found that three-quarters of doctors are concerned about “disruptive physician behavior”; virtually all of the respondents said that it affects patient care. Yet “despite the best efforts of many, our profession is still plagued by doctors acting in a way that is disrespectful, unprofessional, and toxic to the workplace,” ACPE CEO Barry Silbaugh observed.
Ultimately, these issues can be attributed to a fundamental lack of respect between doctors and nurses, who should be considered separate but equal, yet too often are treated as master and handmaiden. To wit: When an attractive, young female East Coast ER doctor didn’t even try to save a man who coded in the ambulance on the way to the hospital, the nurses in the room complained to the hospital’s medical director. The director dismissed the nurses’ complaints patronizingly: “You’re just saying that because she’s young and pretty.”
In Arkansas, an anesthesiologist told a Certified Registered Nurse Anesthetist, “I could teach a monkey to do your job.” CRNAs are advanced-practice nurses with master’s degrees who provide anesthesia either autonomously or under a physician’s supervision. They are “the sole anesthesia providers in nearly all rural hospitals, and the main provider of anesthesia to the men and women serving in the U.S. Armed Forces,” according to the American Association of Nurse Anesthetists. CRNAs told me they are stuck between doctors and nurses. “The medical profession perceives you as a glorified nurse and the nursing profession perceives you as a nurse trying to be a doctor,” said the Arkansas CRNA. “The general public is not aware of what a nurse anesthetist is or that we provide seventy to eighty percent of all anesthesia in the United States.”
The doctor–nurse hierarchy is rooted in the past, in traditionally ingrained remembrances of outdated roles. Up until the mid-twentieth century, nurses were expected to stand when a doctor entered the room, offer him their chair, and open the door so that he could walk through first, in chivalric reverse. Nurses were expected to await instructions passively without questioning the physician. By the 1960s, nursing schools were still teaching that, as one nurse described it, “He’s God almighty and your job is to wait on him.”
In 1967, psychiatrist Leonard Stein described the nurse’s role in an essay entitled “The Doctor–Nurse Game.” The object of the game, he said, was for a nurse to “make her recommendations appear to be initiated by the physician. . . . The nurse who does see herself as a consultant but refuses to follow the rules of the game in making her recommendations, has hell to pay. The outspoken nurse is labeled a ‘bitch’ by the surgeon. The psychiatrist describes her as unconsciously suffering from penis envy.”
Since then, “Nurses have spent the last half century fighting to overcome the stereotype that they are defanged doctors. It’s a division rooted in education, income, and gender. Doctors—men, affluent, with a professional education—reigned supreme in the hospital,” pediatrician Rahul Parikh wrote in a Salon article: “Do doctors and nurses hate each other?” In present-day North Carolina, a physician still expected the medical/ surgical nurses to rise from their seats when he entered the unit. “A couple of the nurses staged a sit-in,” a nurse from that unit told me. “He eventually got the point.”
The current doctor–nurse divide cannot be strongly attributed to gender, however, because some female physicians, like Dr. Baron, can be just as disrespectful as the men. “Female doctors are working in a predominantly male-centered world,” said a Washington State ER nurse. “They want to be respected and heard, but aggressiveness can be confused with assertiveness. They seem to not like to be questioned. A married doctor couple in town is known by the nurses as ‘Bitch and Bitchier.’”
Nurses have continued to battle the stereotypes even as their profession has evolved. They developed specialties and expanded their scope to include more medical tasks. Nursing schools shifted from hospitals, where doctors oversaw the students, to universities, where the instructors are nurses. “Nursing school was now independent of doctors,” New York Times nurse columnist and author Theresa Brown told Parikh in a dialogue for his Salon article. “Yes, we are taught to be patient advocates, but we are also taught to be a check on the doctor. The problem with that is we’re only taught to see docs as adversaries.” Nurses “never get a good understanding of the stresses and strains of what it’s like to be a physician.” If nursing schools don’t share doctors’ perspectives and medical schools don’t teach nurses’ perspectives, then “how do doctors and nurses learn to behave and negotiate with each other?” she asked.
Many physicians trace doctor bullying to behavior they learned in medical school. Kevin Pho, the physician who runs the popular medical blog KevinMD.com, has argued, “Blame should be directed toward the physician education system, rather than doctors themselves. The hierarchical culture that perpetuates bullying goes back as far as medical school, when as students, future doctors are trained in a pecking order not unlike the military. It’s no wonder that some carry that attitude into the workplace.”
In a 2011 survey, doctor bullies blamed a heavy workload and behavior they had learned in medical school and residency. Indeed, Rosenstein has written, “Surgeons have learned that disruptive behavior can intimidate others into doing what they want, and surgical residents seem to learn this behavior by observation.”
If medical school helps to ignite what the ISMP calls a “culture of disrespect among healthcare providers,” then some hospitals and health officials help to perpetuate that hierarchy. In October 2014, when Texas Health Presbyterian Hospital nurse Nina Pham contracted Ebola from a patient, Dr. Thomas Frieden, the head of the Centers for Disease Control and Prevention, seemed quick to appear to blame the victim. “Clearly there was a breach in protocol,” Frieden told Face the Nation. “Infections only occur when there’s a breach in protocol.”